Minority Health (continued, 2)

Recent Findings

Emergency Care/Hospitalization

• Minority children with asthma often use emergency departments (EDs) for care.

  Researchers analyzed 1996-2000 data on 982 children with asthma and found that black and Hispanic children received asthma care in the ED more often than white children, which is consistent with findings from earlier studies. The authors suggest that additional ED visits occur because these children often lack a usual source of care and do not have a plan in place to manage asthma at home when an attack occurs. Thus, improving care access and offering programs to teach caregiver skills to manage asthma may reduce ED visits.

  Source: Kim, Kieckhefer, Greek, et al., Prev Chronic Dis 6(1):Epub, 2009 (AHRQ grant HS13110).

• Rates of potentially preventable hospitalizations are higher among Hispanics than whites.

  Hispanic adults from both poor and wealthy communities are much more likely than whites to be hospitalized for health problems such as uncontrolled diabetes and heart ailments. In contrast, hospitalization rates are about the same for Hispanics and whites with chronic respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). These findings are derived from an analysis of 2006 data from AHRQ's Healthcare Cost and Utilization Project.

  Source: Potentially Preventable Hospitalizations Among Hispanic Adults, 2006, HCUP Statistical Brief 61; online at http://www.hcup-us.ahrq.gov/reports/statbriefs.jsp (Intramural).

• Asian-Pacific Islanders are more likely than whites to die in the hospital from serious but treatable complications.

  Asian-Pacific Islanders are 16 percent more likely than whites to die from serious but treatable complications in U.S. hospitals, according to an analysis of data from AHRQ's Healthcare Cost and Utilization Project. Also, compared with white patients, Asian-Pacific Islanders having surgery are 42 percent more likely to develop blood infection, 34 percent more likely to suffer kidney failure, 14 percent more likely to need a ventilator to assist breathing, and 34 percent more likely to suffer kidney failure. Potential reasons for these disparities include being cared for in hospitals that provide lower quality of care, having cultural or language issues that interfere with doctor-patient communication, or being sicker and more vulnerable to complications than other patients.

  Source: Racial and Ethnic Disparities in Hospital Patient Safety Events, 2005, HCUP Statistical Brief 53; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb53.jsp (Intramural).

• Black patients are more likely than white patients to die after major surgery.

  According to this study, blacks are 23 to 61 percent more likely than white patients to die following certain cardiovascular or cancer surgeries, but the hospital at which they are treated—not their race—accounts for most of this difference in mortality rates. Researchers used national Medicare data to identify all patients undergoing one of eight cardiovascular or cancer procedures between 1994 and 1999. Blacks had higher mortality rates (death before discharge or within 30 days of surgery) than whites for all operations except for lung cancer. Hospitals that treated 10 percent or more black patients had higher mortality rates for all eight procedures irrespective of the patients' race. Black patients were more likely to undergo surgery in very low volume hospitals, a known risk factor for increased mortality. However, some hospitals that treated a large proportion of black patients had higher mortality rates independent of their procedure volume, underscoring the need to improve quality of care at poor-performing hospitals.

  Source: Lucas, Stukel, Morris, et al., Ann Surg 243(2):281-286, 2006 (AHRQ grant HS10141). See also Fiscella, Franks, Meldrum, and Barnett, Ann Surg 242(2):151-155, 2005 (AHRQ grant HS10910); Groeneveld, Laufer, and Garber, Med Care 43(4):320-329, 2005 (AHRQ grant T32 HS00028).

• Study finds disparities in use of strong pain medications in hospital EDs.

  Researchers analyzed treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005 and found that 23 percent of blacks, 24 percent of Hispanics, and 28 percent of Asians received opioids for pain, compared with 31 percent of whites. Although the use of opioids to treat pain increased overall from 23 percent in 1993 to 37 percent in 2005, the differences in use among racial/ethnic groups did not diminish. In 2005, the last year of the survey, 40 percent of whites in pain received opioids compared with 32 percent of all others. Differences in prescribing for whites, Hispanics, and blacks were greater among those with the worst pain; opioids were prescribed for 52 percent of whites, 42 percent of Hispanics, and 39 percent of blacks with severe pain.

  Source: Pletcher, Kertesz, Kohn, and Gonzales, JAMA 299(1):70-78, 2008 (AHRQ grant HS16238). See also Chen, Kurz, Pasanen, et al., J Gen Intern Med 20:593-598, 2005 (AHRQ grant HS10861).

• Hospital admissions for the sickest children are similar for white, black, and Hispanic children.

  Researchers examined severity-adjusted emergency department pediatric admission rates in a 13-site sample of 8,952 children (3,112 white, 3,288 black, and 2,552 Hispanic) and found that the sickest children (those in the two highest illness severity quintiles) in all three groups were admitted at similar rates. They also found that white children in the lowest illness severity quintiles were admitted at 1.5 to 2 times the expected rate, suggesting that white children were overadmitted when not severely ill but not that black and Hispanic children were being denied essential admissions.

  Source: Chamberlain, Joseph, Patel, et al., Pediatrics 119:1319-1324, 2007 (AHRQ grant HS10238).

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Health Care Access, Costs, and Insurance

• Asian Americans enrolled in traditional fee-for-service Medicare receive fewer needed services than white patients.

  Researchers examined the association of race/ethnicity and socioeconomic status with the use of two Medicare-covered cancer screening services (colorectal cancer screening and mammography) and three diabetes-related care services (blood sugar measurement, eye exams, and self-care instructions) among elderly whites and Asian Americans. The study focused on the metropolitan statistical areas (MSAs) with the largest number of elderly Asians in 2000, including Los Angeles, New York City, and Washington, DC. Asians were less likely than whites to receive colorectal cancer screening and mammography, while Asian-white disparities in diabetes care were less consistent and varied according to geographic region. Outside of the nine MSAs studied, Asian-white differences were significant across both cancer screening services and all three diabetes services. Cancer is the leading cause of death among Asians, and diabetes-related conditions rank fifth.

  Source: Moy, Greenberg, and Borsky, Health Aff 27(2):538-549, 2008 (AHRQ Publication No. 08-R064)* (Intramural).

• Minority children are half as likely as white children to receive specialized therapies.

  This study found that 3.8 percent of children aged 18 or younger obtain specialized therapies from the health care system, including physical, occupational, and speech therapy and home health care services. Children most likely to use specialized therapies tend to be male (59.7 percent), white (80.6 percent), and have a chronic condition (38.8 percent). Black children, Hispanic children, and children of other races were much less likely than white children to receive special therapies. These findings suggest that either minority children are underusing therapies or white children are overusing them, according to the researchers.

  Source: Kuhlthau, Hill, Fluet, et al., Dev Neurorehabil 11(2):115-123, 2008 (AHRQ grant HS13757).

• Hispanics with limited English proficiency access health care less often.

  According to an analysis of 2004 data from AHRQ's Medical Expenditure Panel Survey (MEPS), only about 49 percent of Hispanics who are not comfortable speaking English have a regular source of medical care (e.g., family doctor or community clinic), compared with 63 percent of Hispanics who are proficient in English. About 6 in 10 Hispanics with limited English proficiency are uninsured, compared with 3 in 10 who are proficient in English. In addition, Hispanics with limited English proficiency are less likely than their more proficient counterparts to visit a doctor or clinic, go to an emergency room, have a prescription filled, or visit a dentist.

  Source: Demographics and Health Care Access of Limited-English-Proficient and English-Proficient Hispanics, MEPS Research Findings 28; online at http://meps.ahrq.gov/mepsweb. Also go to Health Insurance Status of Hispanic Subpopulations in 2004: Estimates for the U.S. Civilian Noninstitutionalized Population Under Age 65, MEPS Statistical Brief 143; online at http://meps.ahrq.gov/mepsweb/data_stats/Pub_ProdResults_Details.jsp?pt=Statistical%20Brief&opt=2&id=779. (Intramural).

• More blacks than whites have trouble affording their prescription medicines.

  Researchers recruited elderly black and white patients from 48 primary care practices in Alabama. Patients were asked about their ability to pay for prescriptions, their insurance coverage, coexisting medical conditions, and socioeconomic status. Blacks were twice as likely as whites to not fill a prescription (50 vs. 25 percent) and were far more likely to report inadequate income to meet basic needs (61 vs. 17 percent). Of 399 participating patients, 53 percent had an annual household income of less than $15,000.

  Source: Cobaugh, Angner, Kiefe, et al., Am J Health Syst Pharm 65:2137-2143, 2008 (AHRQ grant HS10389).

• Whites are more likely to seek distant hospital care for less severe illness than minorities.

  This study analyzed the hospitalization patterns of elderly residents of New York to determine whether the relation between distance traveled for care and severity of illness was uniform across racial/ethnic subgroups. The researchers used hospital discharge data, which they linked to other data files, and found that minorities had to be more severely ill than whites before they sought distant hospital care. If costly elective services were to be regionalized to take advantage of high volume for both cost and quality of care, extra outreach efforts would be needed to reduce disparities in appropriate care, note the researchers.

  Source: Basu and Friedman, Health Econ 2006; online at www.interscience.wiley.com (AHRQ Publication No. 07-R029)* (Intramural). See also Basu, J Health Care Poor Underserved 16:391-405, 2005 (AHRQ Publication No. 05-R054)* (Intramural).

• Immigrants use fewer preventive services than U.S. natives.

  Researchers compared use of preventive care services by immigrants and native-born residents and found that U.S. natives had more medical and dental visits, received more flu shots, and were screened more often for high cholesterol levels and cervical, breast, and prostate cancers. Although immigrants' use of preventive services increases the longer they stay in the United States, their use never matches that of U.S. natives. Immigrants are likely to be uninsured when they arrive in the United States, but even after they obtain continuous coverage, they still are less likely than U.S. natives to use preventive care.

  Source: Pylypchuk and Hudson, Health Econ; E-pub August 2008 (AHRQ Publication No. 09-R025)* (Intramural).

• Minority children with special needs are much less likely than similar white children to receive vision care.

  Nearly 6 percent of U.S. children with special health care needs (CSHCN) do not receive needed eyeglasses or vision care, and black, Latino, and multiracial CSHCN are two to three times as likely as white children to have an unmet need for vision care. Researchers examined 2000-2002 survey data on a sample of 14,070 CSHCN who needed eyeglasses or vision care in the preceding year. Disparities in receipt of vision care persisted even after allowances were made for differences in health status and other child and family characteristics, such as insurance or income.

  Source: Heslin, Casey, Shaheen, et al., Arch Ophthalmol 124:895-902, 2006.

• Hispanics enrolled in Medicare managed care plans are less positive than whites about their care experiences.

  More than half of Hispanics insured through Medicare were enrolled in managed care programs in 2002. A 2002 survey included 125,369 respondents enrolled in 181 Medicare managed care programs nationally. Responses from white enrollees were compared with responses from Hispanic enrollees; also, responses from Hispanics who completed the survey in English were compared with those who completed the survey in Spanish. English-speaking Hispanics viewed all aspects of their care—except provider communications—worse than whites did. Spanish-speaking respondents reported more negative care experiences with timeliness of care, provider communications, and office staff helpfulness but were more satisfied with getting needed care.

  Source: Weech-Maldonado, Fongwa, Gutierrez, and Hays, Health Serv Res 43(2):552-568, 2008 (AHRQ grant HS16980). See also Basu, Friedman, and Burstin, J Health Care Poor Underserved 17:101-115, 2006 (AHRQ Publication No. 06-R028)* (Intramural).

• Community-based case managers increase public insurance enrollment of uninsured Latino children.

  This study found that using bilingual community-based case managers to help poor Latino children enroll in Medicaid or the Children's Health Insurance Program (CHIP) reduced the proportion of such children who were uninsured and eliminated the disparity in coverage between Latino children and children of other races/ethnicities. The researchers randomly assigned uninsured Latino children aged 18 and younger from two Boston-area communities to either an intervention group using trained case managers or a control group that received traditional Medicaid and CHIP outreach efforts. They found that 96 percent of 139 uninsured children who received the intervention enrolled in either Medicaid or CHIP between May 2002 and September 2003, compared with 57 percent of children in the control group.

  Source: Flores, Abreu, Chaisson, et al., Pediatrics 116(6):1433-1441, 2005 (AHRQ grant HS11305).

• Researchers examine the effects of various factors on children's health insurance coverage.

  Children of different racial and ethnic groups vary substantially with respect to health insurance coverage. These researchers explored how much a given characteristic contributes to coverage differences, using a recently developed statistical technique—decomposition analysis. They found that observable characteristics such as poverty, parent educational level, family structure (for black children), and immigration-related factors (for Hispanic children) account for 70 percent or more of the coverage differences among white, black, and Hispanic children. They conclude that the lower coverage levels among ethnic and racial minorities are due to the fact that uninsurance is concentrated among socioeconomically disadvantaged children who happen to be minorities.

  Source: Pylypchuk and Selden, J Health Econ 27(4):1109-1128, 2008 (AHRQ Publication No. 08-R068)* (Intramural). See also Flores, Abreu, Brown, and Tomany-Korman, Ambul Pediatr 5(6):332-340, 2005 (AHRQ grant HS11305); Shone, Dick, Klein, et al., Pediatrics 115(6):697-705, 2005 (AHRQ grant HS10450); Simpson, Owens, Zodet, et al., Ambul Pediatr 5(1):6-44, 2005 (AHRQ Publication No. 05-R048)* (Intramural).

• Reductions in care use under Medicaid primary care case management are more dramatic for minority children.

  Primary care case management (PCCM) programs are designed to increase patients' use of primary and preventive care in doctor's offices, while decreasing use of specialty and urgent care. However, disruptions in care use required by PCCM in Alabama and Georgia had an unexpected negative effect on children, especially minority children, according to this study. Implementation of PCCM in these two States reduced primary care visits for children, both through the gatekeeper function and changes in provider availability. PCCM was associated with lower use of primary care for minority children, but not white children, in Georgia. PCCM reduced preventive care for white and black children in urban Alabama and for black children in urban Georgia.

  Source: Adams, Bronstein, and Florence, Med Care Res Rev 63(1):58-87, 2006 (AHRQ grant HS10435).

• Changes in HMO membership alone are unlikely to affect disparities in receipt of primary care.

  Researchers examined national data on primary care office visits during the years 1985, 1989-1992, and 1997-2000 and found that blacks were less likely than whites to receive a Pap test, a rectal exam, smoking cessation advice, or mental health advice, but they were more likely to receive advice on diet and weight and a followup appointment. There was no significant association between receipt of primary care services and either HMO membership or physician level of HMO participation. There also was no association between receipt of care and patient race, Medicaid coverage, percentage of Medicaid patients in the practice, or duration of the visit.

  Source: Fiscella and Franks, Am J Manag Care 11(6):397-402, 2005. See also Franks, Fiscella, and Meldrum, J Gen Intern Med 20:599-603, 2005 (AHRQ grant HS10910).

• American Indians and certain other groups cannot easily access specialized cancer care.

  Previous studies have shown that patients with a greater travel time for care are more likely to be diagnosed with advanced cancer, have decreased use of breast-conserving therapy, and have lower enrollment in clinical trials. This study found that compared with the overall U.S. population, American Indians, nonurban residents, and people living in the South travel further for specialized cancer care. The median travel time for all U.S. residents to a specialized cancer center is 78 minutes; Asians have the shortest travel time (28 minutes), and American Indians the longest (155 minutes). Compared with residents of the Northeast, travel time is five times as long for people in the South, three times as long for residents of Western States, and more than twice as long for those living in the Midwest.

  Source: Onega, Duell, Shi, et al., Cancer 112(4):909-918, 2008 (AHRQ grant T32 HS00070).

• Access to primary care is very limited for Latinos of Mexican origin living in nonmetropolitan areas.

  An analysis of 2002-2003 data from AHRQ's Medical Expenditure Panel Survey indicates that nonmetro Mexicans face substantial barriers to accessing timely health care, compared with their metropolitan counterparts. According to the study, Mexicans living in nonmetro areas were 45 percent less likely than metro whites and 49 percent less likely than metro Mexicans to have a usual source of care. Possible reasons for this disparity include more marginalization of Mexicans in smaller communities and reduced English ability among providers who also are unable to provide interpreters.

  Source: Berdahl, Kirby, and Stone, Medical Care 45(7):647-654, 2007 (AHRQ Publication No. 07-R059)* (Intramural). See also Ku and Flores, Health Aff 24(2):435-444, 2005 (AHRQ grant HS11305); McCabe, Morgan, Curley, et al., Ethn Dis 15:300-304, 2005 (AHRQ grant HS10637).

• Greater access to physicians may narrow mortality differences between older blacks and whites.

  Black people aged 65 and older in Tennessee made more trips to the emergency room than same-age whites (2.6 vs. 2.1 visits, respectively) and had more hospitalizations (1.34 vs. 1.25, respectively), while whites averaged 7.5 more trips to the doctor during the 5 years of observation, according to this study. The researchers used 1996-2002 Medicare data on 665,887 beneficiaries in Tennessee to assess physician-diagnosed conditions, health service use, and mortality. Their findings held even after accounting for racial differences in diagnosed medical conditions, socioeconomic status, and use of other health care services. They conclude that delaying treatment until emergency services are required may increase mortality rates for older blacks and could account for the disparity in black-white mortality rates.

  Source: Sherkat, Kilbourne, Cain, et al., Res Aging 29(3):207-224, 2007 (AHRQ grant HS11640).

• Low income minorities and whites often self-treat severe toothache.

  Researchers conducted focus group sessions with 66 low-income Hispanic, black, and white adults to examine how they coped with toothache pain. All of the participants had suffered toothache in the past year and had used self-care or care from a nondentist provider to relieve their pain. These individuals described their toothache pain as intense, throbbing, miserable, or unbearable and reported that it was bad enough to affect their ability to perform their regular activities, such as working, housework, social activities, eating, and sleeping. Some resorted to getting arrested to get dental care, others pulled their teeth out themselves or rinsed with caustic substances in an attempt to relieve the pain. Most reported the high cost of dental care as the predominant barrier to seeking care from a dentist. Some also cited mistrust and fear, as well as long waiting lists and lack of sick leave as barriers.

  Source: Cohen, Harris, Bonito, et al., J Public Health Dent 67(1):28-35, 2007 (AHRQ Publication No. 07-R072)* (Intramural).

• Ethnic differences in attitudes and beliefs about knee replacement surgery may contribute to the disparities in its use.

  Researchers conducted focus groups with 37 patients (two black groups, two white groups, and two Hispanic groups) who had knee osteoarthritis to examine differences in racial/ethnic attitudes about total knee replacement surgery. Differences were most obvious in explanations of illness, perceived changes in lifestyle, physician and health care system trust, and attitudes about paying for surgery. Blacks and Hispanics described their knee pain as being more debilitating than whites did; whites were more likely to describe ways in which they overcame those limitations. Trust in their doctor was pivotal in the surgery decision for Hispanics; blacks were more willing to pay for the surgery, even if it meant borrowing money, to alleviate their pain.

  Source: Kroll, Richardson, Sharf, and Suarez-Almazor, J Rheumatol 34:1069-1075, 2007 (AHRQ grant HS10876). See also Kane, Wilt, Suarez-Almazor, and Fu, Arthritis Rheum 57(4):562-567, 2007 (AHRQ contract 290-02-0009); Byrne, Souchek, Richardson, and Suarez-Almazor, J Clin Epidemiol 59:1078-1086, 2006 (AHRQ grant HS10876); Bradley, Deutsch, McKendree-Smith, and Alarcon, J Rheumatol 32(6):1149-1152, 2005 (AHRQ grant HS10389); Souchek, Byrne, Kelly, et al., Med Care 43(9):921-928, 2005 (AHRQ grant HS10876); Suarez-Almazor, Souchek, Kelly, et al., Arch Intern Med 165:1117-1124, 2005 (AHRQ grant HS10876).

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